Provider Demographics
NPI:1053986430
Name:MULLANE, MARY ANN (PT)
Entity type:Individual
Prefix:
First Name:MARY ANN
Middle Name:
Last Name:MULLANE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 FATHOM DR APT 208
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94404-1066
Mailing Address - Country:US
Mailing Address - Phone:858-722-8187
Mailing Address - Fax:
Practice Address - Street 1:1090 S HWY 89
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8511
Practice Address - Country:US
Practice Address - Phone:307-733-5577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32381225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist